ideas on correcting med error

[chapsam]

Hi fellow nurses,

I'm working on a best practice project at my hospital in a nursing program for new nurses. I've found a hole that needs plugging in terms of an easy to make med error. This is the scenario...

We use an emar and everything has to be scanned (including the pt) before meds are given. So, the scheduled fluids are timed and you are supposed to scan them off when they show up as due. However, 99% of the time the bag has finished before it comes up on the mar or hours after it has come up. This usually works out ok because we just scan a new bag and hang it up behind the current bag and then just replace as needed. This usually works out fine but it can also lead to some errors. For instance, I got an order for a 1x bag of fluid. I did not see the one time so did not communicate that to the next nurse. She kept the bags going and so did I most of the next day. Another scenario is that the order gets d/c'd & the nurse doesn't catch it and bags just continue to infuse. It's pretty easy to miss both of those scenarios. No one got hurt in my scenario (or not too bad) and I've learned from it. But, I would like to help plug that hole because I think it's common given that fluids are stopped & started all the time (pt showers, goes to radiology, etc...) & never match up to the emar.

Does anyone work in a hospital that has a plan in place for that scenario or perhaps you have a personal method that works that I could translate into a best practice.

Thank you!

[MunoRN, RN]

If a charting action comes up and you don't need to hang a new bag yet, or if you need to hang a new bag and there isn't a charting action for another two hours, a functional EMR should allow the nurse to re-time the new bag charting action. Where an EMR becomes useless is when it leaves nursing with little choice other than to ignore it all together. If the EMR works properly, an order for NS x 1 liter should only have one charting action, so that when a nurse goes to hang another bag they'll notice there are no additional charting actions, which should clue them into the fact that it's only x1 liter.

[BonnieSc]

Yes, places I have worked have retimed it--but also, the nurse should be thinking about the order. Most patients do not need to be on continuous IV fluids. I'm sorry it isn't a good "tech" solution or an easy fix, but it never hurts to remind the nurses to think about the reason for an order and whether it's appropriate. If the nurse in this scenario had wondered why the patient was on continuous fluids, she might have looked at the order and noticed the "one time", which I agree is easy to miss. But like the previous poster, I would expect the fluid to disappear from the eMAR altogether (as a current med) after it was scanned the one time, creating an alert when someone scanned a second bag, whether it was hung "on time" or not. That seems like a bug in the system.

[SubSippi]

In our computer system, the fluids actually say continuous next to them, if that's what they are. If it's just for one bag, it says something like 1000mL normal saline X1.